Crosswalk for Elimination of Exhibits

Explanation of Burden Reduction

For

Form CMS-339 (Provider Cost Report Reimbursement Questionnaire

The significant burden reduction is due to the fact that the information reported in the past by hospitals, SNFs, and ESRD facilities on Form CMS-339 has been incorporated into the new cost reports for those providers (i.e., into Form CMS-2552-10 for hospitals, Form CMS-2540-10 for SNFs, and Form CMS-265-11 for ESRD facilities.) Therefore, we are asking for an extension of Form CMS only for the remaining provider-types, namely HHAs, CMHCs, freestanding RHCs/FQHCs, OPOs, and Hospices. We also eliminated former exhibits 2 through 4A and 6 because these exhibits were applicable only to hospitals and SNFs. (Former Exhibit 5 has been renumbered as Exhibit 2.)

These deletions resulted in a 355,523 decrease in the estimated hours necessary to complete Form CMS-339 (i.e., the difference between the 431,148 hours reported for the previous burden and the 75,625 estimated hours applicable to this extension request).